Provider Demographics
NPI:1598157984
Name:SULLIVAN, ANGELA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:ANGELA
Other - Middle Name:
Other - Last Name:POOLAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:6960 DESTINY DR
Mailing Address - Street 2:SUITE 112
Mailing Address - City:ROCKLIN
Mailing Address - State:CA
Mailing Address - Zip Code:95677-2993
Mailing Address - Country:US
Mailing Address - Phone:916-415-0119
Mailing Address - Fax:916-415-0120
Practice Address - Street 1:6960 DESTINY DR
Practice Address - Street 2:SUITE 112
Practice Address - City:ROCKLIN
Practice Address - State:CA
Practice Address - Zip Code:95677-2993
Practice Address - Country:US
Practice Address - Phone:916-415-0119
Practice Address - Fax:916-415-0120
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-23
Last Update Date:2015-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15499235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist